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T e c h n i c a l S e m i n a r s
Sick Young InfantInfant Mortality
Overview
Neonatal MortalityGlobal Estimates • Causes
IMCI GuidelinesInfection-related Mortality & Morbidity
First Week of Life
WHO Multi-center StudyRationale • Description
11-item Model to Predict Serious Disease
Clinical Features • Positive Blood Culture Isolates
Gram Positive & Negative Organisms
Conclusions
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Major improvements in “under 5” mortality, mostly after neonatal period
• 5 million newborn deaths each year, 98 percentin developing countries (still an underestimate)
• About 2/3 of the infant mortality occurs in the first month of life
– from asphyxia, birth trauma, infection, prematurity and malformations during first week
– from sepsis, pneumonia, meningitis, diarrhoeal disease and tetanus during remainder of first month
Infant MortalityOverview
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
0
0.5
1
1.5
2
2.5
3
3.5
1st w
eek
1-4
weeks
1-1
2 m
ths
deaths(millions)
Infant MortalityOverview• 126 million live
births• 8 million infant
deaths• 5 million neonatal
deaths• 3.3 million early
neonatal deaths
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
Region Live births(thousands)
Neonataldeaths
(thousands)
Neonatalmortality rate
Africa 30,700 1,300 42
Asia 83,400 3,400 41
Latin America 12,000 300 25
Oceania 223 5 24
Europe 8,300 66 8
North America 4,400 26 6
Weekly Epidemiological Record, October 1996
Neonatal MortalityGlobal Estimates
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Improving maternal care during pregnancy, delivery and the postnatal period could reduce mortality– practising clean delivery
– basic newborn resuscitation when needed
– prevention of hypothermia
– early and exclusive breast feeding
– management of syphilis and tetanus vaccination
• However, most deliveries occur in the home and are supervised by traditional birth attendants, or are unattended.
Neonatal MortalityGlobal Estimates
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• 5 Million Deaths Per Year– Infection - 1.78 million– Birth asphyxia/trauma - 1.38 million
• good antenatal care and safe supervised deliveries could prevent
– Prematurity - 1.15 million
• very difficult to improve without major improvements in the socioeconomic situation
– Congenital anomalies - 0.52 million
– Other perinatal causes - 0.17 million
WHO MSM Programme
Neonatal MortalityCauses
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Infections make up a major portion of the preventable and treatable causes of neonatal mortality
– Pneumonia - 750,000
– Tetanus - 350,000 (declining rates)
– Sepsis - 300,000
– Diarrhoea - 150,000 (but with improvement due to exclusive breastfeeding)
– Meningitis - 50,000
Neonatal MortalityCauses
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Directly or indirectly, IMCI addresses all the major infection- related causes of mortality and morbidity in the young infant.
– Clinical indicators to identify and treat serious bacterial infection and diarrhoeal disease
– Prevention of tetanus through the maternal tetanus toxoid immunization
– Addressing the issues of prematurity and low birth weight trough assessment and management of feeding problems
– Prevention of ARI, diarrhoeal diseases and other infectious and nutritional diseases through promotion of exclusive breastfeeding
IMCI GuidelinesInfection-related Mortality & Morbidity
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• IMCI guidelines do not include the first week of life because:– mortality usually related to pregnancy/delivery
– entails expanding IMCI to include preventive measures during labor and delivery
– maternal recognition of these conditions is poor
– sick newborn baby is often kept at home
IMCI GuidelinesFirst Week of Life
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Lack of data from developing countries on serious bacterial infections in the young infant
• Prior hospital studies identified mostly gram negative bacilli
• Differentiation from nosocomially-acquired and community-acquired pneumonia was difficult
• Ability to identify antibiotics based on current organisms and their sensitivity patterns was important
WHO Multi-center StudyRationale
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Four developing countries– Papua New Guinea, The Gambia,
The Philippines, Ethiopia
• 4,552 sick infants under 90 days of age– All infants with signs of infection investigated – Full history and examination on every infant – Outcome of all cases recorded
WHO Multi-center StudyDescription
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Four Vital Signs (age, temperature, respiratory rate, weight for age z score)
• Seven Clinical Findings– No arousal with minimal stimulation– History of change and activity – History of convulsions– Inability to suck – Definite lower chest wall indrawing– Crepitations– Cyanosis
WHO Multi-center Study11-item Model to Predict Serious Disease
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• 167 infants had proven bacterial infection
• Staphylococcus aureus, Streptococcus pneumoniae and Group A ß-hemolytic Streptococcus most common cause (60 percent)
• E. coli, Salmonella spp. and other gram negative organisms accounted for a much lower proportion than expected
• Streptococcus pneumoniae alone was almost as important as E. coli and Salmonella spp. combined
WHO Multi-center StudyPositive blood Culture Isolates
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Two important conclusions:
– Gram positive cocci were more importantthan gram negative bacilli in causing serious bacterial infections in the young infant.
– S.pneumoniae are a significant cause of serious bacterial infection in young infants, a previously unrecognized observation.
WHO Multi-center StudyPositive blood Culture Isolates
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• 5.4% of the infants in the study (249) died:– Blood culture positive (31% died)– Blood culture negative ( 9% died)
• Death associated with:– Positive CSF or blood culture– Hypoxaemia– Major chest radiographic abnormality– Abnormal white cell count (<5.5 or >22)
WHO Multi-center StudyClinical Features
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Group A ß Hemolytic Streptococcus and Staphylococcus aureus common cause of neonatal sepsis and death
• Group B Streptococcus rarely isolated in the study
• Streptococcus pneumoniae caused 33 percent of deaths
• Group A ß Hemolytic Streptococcus caused 14 percent,
Mean age of disease between 33 47 days
WHO Multi-center StudyGram Positive Organisms
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Gram negative organisms were less common but accounted for higher mortality
• Mostly in undernourished younger infants
• Common in hospital setting (nosocomial transmission), but rarely reported in WHO multi-center study
• Isolated most commonly during the first month of life
WHO Multi-center StudyGram Negative Organisms
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Infection is a major contributor to high mortality rates in very young infants in developing countries.– Most likely bacterial causes:
• Streptococcus pneumoniae
• Group A Streptococcus
• Staphylococcus aureus
• Gram negative enteric organisms, especially E. coli
WHO Multi-center StudyConclusion
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Benzylpenicillin and gentamicin for Streptococcus pneumoniae, Group A Streptococcus and E. coli.
• Cloxacillin for Staphylococcus aureus, other gram positive cocci.
WHO Multi-center StudyConclusion
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Refer those who have persistentdiarrhoea AND who are also dehydrated to hospital– mortality is 8 to 10 times higher than that with acute
diarrhoea
– may need nutritional rehabilitation
– may need investigation for immune deficiencies and/or resistant bacteria
Severe Persistent DiarrhoeaClassification
S i c k Y o u n g I n f a n tS i c k Y o u n g I n f a n t
• Correct Dehydration
• Correct Nutritional Problems– Reduce disaccharides– Increase energy intake– Supplement micronutrients (possibly)
• Give Antibiotics for Dysentery
• Avoid These Therapies– Antibiotics for watery diarrhoea– Anti-motility agents– Diluted feeds
Persistent DiarrhoeaTherapy